What does "Client-centered" mean to me?

 

"It is important to remember that each person experiences disability in a completely personal way."- S. Brooks

 Tick tock...Tick tock...Tick tock- children don't even realize that 24 hours have lapsed as their day is dominated by Play. Adolescents on the other hand, wish they could go back to their childhood as they are too stressed about passing their grades and being up to date. Adults are drowning in their vocational demands and the elderly often have nothing but leisure. Journeying through our lives, we all engage in our own occupations on a daily basis. We do what we each personally want to do along with what is expected of us socially and culturally.   

Hence we see, that for every age group, engagement in occupation is different. Putting on my thinking cap and delving deeper, participating in every day tasks for INDIVIDUALS is unique because no one-person is the same as the other. Essentially, we all sleep, do self-care, walk and talk, but each in their distinctive manners. Hence, the foundation of OT is enabling the client to do what is meaningful to them. It means looking at them holistically-considering them psychologically, physically, spiritually, culturally and contextually- and centering treatment around their habits, routines, roles and rituals. It means putting aside conventional methods of conducting tasks and focusing intervention on enabling them to do what is most valuable to them.

A practical example of this would be my treatment planning and implementation for my patient this week. Agreed that occupation has therapeutic potential. However, if occupation is used irrelevantly, it is inefficacious. It would have been futile if my treatment sessions entailed making food on a stove top, with food processors and all sorts of fancy adaptive cutlery and boards. Although she would eventually be able to independently cook and clean in that setup, the question remains- Have I enabled her to function independently? and the answer is a stark No, because back in her rural settlement, she does not have access to all these urban tools and technological advancements. Her family cooks on open fire, uses basic cutlery and does everything manually. Hence my session would have been pointless as the patient would be inefficient in her environment. Likewise, I would not work towards regaining her dressing abilities in pants and a blouse as she only wears skirts and a loose top.

That is why adopting  a client-centered approach is VITAL, because instead of me "presuming" what is beneficial for the client, I have to reposition my thinking to entail in my treatment sessions what the client will eventually do when she is home.  Hence, since my aim at the moment is balance retraining, my treatment was focused around achieving good static and dynamic balance for her. This was done by involving her in leisure and home management tasks in sitting with the necessary structural adaptations to achieve my goals for her. Since she was a machinist premorbid, her leisure activity involved sewing. If I chose board games as leisure then it would have been pointless as firstly, it is not relevant to her context and secondly she would not choose to participate in that thereby defeating the purpose of the activity. Because, what is the point of teaching her something she will not be executing at home. Furthermore, I got in touch with the social worker to contact her family and schedule caregiver training specific to her environment. 

In all honesty, being so accustomed to an urban lifestyle whilst practicing in a rural setting, it is sometimes tempting to lose sight of the fact that we are all unique individuals with personal goals and aspirations. Hence engraining a client-centered approach in my foundational learning is vital because as an Occupational Therapist on the Rehabilitation team, my ultimate role is to enable patients to regain function so they can live as independently, productively and meaningfully in the future as possible. 

From Theory into Practice

"Experience without theory is blind, but theory without experience is mere intellectual play." ~ Immanuel Kant

Login to Learn2021 and meet OT341, OT342 and OT344. Their aim is to educate around “therapy” with slides and videos. I learn various diagnoses, related intervention principles and clinical reasoning. These are important of course. However, not adequate for practical application. Let’s agree that reason, and the ability to use it are two separate skills. In therapy, excelling in the former only is like a stagnant wheelchair with all its parts intact but nowhere to go.

So, I awoke around 4:40 am that Wednesday morning due to my anxieties around lack of confidence in treating patients overpowering my ability to understand that; I am a student. This meant that I could make mistakes and learn from them. No-one was going to jail me for it as such. However, students are students and with the workload and expectations to be met, their mental health is bound to take a toll at one point or the other. My only consolation was that I had been to the facility before, hence the familiarity had somewhat reduced the intimidation I would naturally have encountered. Because, who isn’t afraid of the unknown?

Tracing back to that week, I was handed a referral. My very first “referral” as an OT student. This carried a heavy responsibility of ensuring that whatever I conducted, be it my sessions or myself had to be very ethical and beneficial. There was now, no just leaving things at assessing the patient and finishing off with a problem list and recommendations. I had to now prioritise solving these problems to achieve the best possible quality of life for my patient. The referral handed out to me entailed a 55-year-old female patient post her spinal fusion operation due to TB Spine. Racing through my head, were the notes on Spinal Cord Injuries. Now was THE TIME, to physically practice whatever I had envisioned in those notes. With deep breaths in an out and mentally chanting: “I got this! “I know this, and I can do this successfully”, I navigated to the ward. Phewww!

Trust me when I say that my anxieties reduced to a whole half after I met the patient and connected with her. Firstly, she could speak English which eliminated the risk of any language barrier. This paved the way for effective communication and exchange of concerns and plans. Furthermore, she was SO keen on regaining function and co-operating, which in turn pumped enthusiasm in me to work with her. Finally, I was somewhat excited as I should have been.

Hence, I began by screening her bed mobility which gave me an indication of her problematic limbs. To obtain more accurate findings, I had her seated at the edge of the bed and conduct whatever active movements she could. Moreover, I assessed her seated balance. We attempted a transfer onto a wheelchair to further obtain an idea of her functional mobility, however she did not have enough strength in her legs to stand. Upon gathering for feedback, I gained a TONNE of perspective into my handling principles and conducting treatment appropriately. There were two things which my supervisor taught that day, which stuck with me. He explained that OT begins from the time one opens their eyes in the morning and ends when they open it the next morning because it includes sleep as well. Hence, begin with the basics like rolling onto your side to fetch your phone and sitting up at the edge of your bed to walk out. Therefore, for my next session, I planned it around increasing the patient’s knowledge in sleeping positions and helping her regain independent bed mobility.  Secondly, he created an analogy of treatment as follows- He said: “Treatment is like a three-legged man. You consider the patient in 3 lights. (1) Who they were before, (2) Who they are now and (3) Who they will be after treatment.” This taught me to consider the person premorbid, evaluate the function they have lost currently in relation to the function they had premorbid, and work towards achieving a level of independence for them similar to their premorbid. In my case, the patient was using a walking frame to ambulate before her TB Spine. Hence, my aim will be to enable her to at least stand using a walking frame for her transfers. Thereafter, I look forward to equipping her with wheelchair mobility skills as she cannot walk due to extremely limited active movement in her lower limbs.

My second supervisor was quite pleased that I had transferred my patient from a cot bed to a standard hospital bed. The cot bed had no settings to raise her up in bed and was too high to initiate safe standing. Consequently, the patient was lying down the whole day, which was only stiffening her back more. Hence, changing her bed allowed her to be raised in bed thereby creating room to change her back positions. This also served as pressure relief for her back to some extent. Furthermore, for future sessions, I can now initiate safe standing as it has different height settings as well. Her advice to me was to be more cautious of safety principles such as teaching the patient to centralise herself in bed before rolling so as to not fall over. Furthermore, she advised to incorporate leisure in sitting to work on her sitting balance, endurance and constructive use of leisure time. She suggested sewing as an activity as the patient was employed as a machinist premorbid.

To my surprise, I spent much less time on assessment as compared to previously wherein I would spend an ENTIRE day on them. Instead, I accomplished much more by moving through my assessments swiftly and accurately, along with treating for most of the half day. There has definitely been a shift in my practical work in that sense.

Conclusively, putting theory into practice really solidifies the skills I have learnt. It takes my intellectual abilities and puts them into action to equip me with the skills to be a practicing OT. I look forward to encountering more diagnoses and challenges along this path to mould me into a competent OT.